VT-O治療女性壓力性尿失禁ppt課件

1、TVT-O治療女性壓力性尿失禁治療女性壓力性尿失禁* Trademark TVT的尿道中段懸吊曾經(jīng)成為“金規(guī)范 Long-term, seven year follow-up data presented at 2003 IUGA reported+ Cure rate of 81% Significantly improved rate of 16% Comparable to 5 year data of 85% / 11% respectively Very low rates of reported major complications in over 500,000 patient

2、s Reported bowel injury less than 6 / 100,000 procedures Reported major vascular injury less than 9 / 100,000 procedures+ Nilsson, et. al, 7 Year Follow-up of the Tension-free Vaginal Tape (TVT) Procedure; International Urogynecology Journal, IUGA Abstract # 116 (89); October, 2003.Complication US E

3、x-US Total %血管損傷血管損傷 7 37 44 0.009 尿道磨損尿道磨損20 0 20 0.004腸損傷腸損傷16 12 28 0.006神經(jīng)損傷神經(jīng)損傷 3 1 4 0.0008血腫血腫 4 16 20 0.004Most Significant Reported Complications+Based on over 500,000 patients treated worldwide+ As of September 26, 2003, seven deaths are associated with GYNECARE TVT. Six cases were for bow

4、el perforation. Five were associated with undiagnosed bowel perforations at the time of surgery. In the sixth case of bowel perforation, no additional information could be obtained. The seventh case was associated with a woman who had a bleeding disorder who died from uncontrolled postoperative blee

5、ding in the retropubic space. Professor Jean de Leval, Chairman of Urology at the University of Liege, Belgium 避開恥骨后空間能夠帶來的益處減少膀胱穿孔，尤其對有手術(shù)史的病人防止恥骨后血腫防止腸穿孔減少大血管的損傷懸吊帶方向的改動能夠帶來的益處 減少術(shù)后尿潴留的發(fā)生率手術(shù)時間更短Retropubic Slings (“U shaped)F1F1F2F2 Obturator Slings(Hammock Shaped)-Hammock shape of sling may result

6、in less obstructive symptoms and/or de novo urgency, since it is harder to overcompress the urethra -懸吊帶方向的改動減少梗阻的發(fā)生和術(shù)后急迫病癥- However, this may also make it more difficult to correct certain patients, such as those with ISD- 但是，對于ISD的病人能夠不能完全糾治 Consists of three major components GYNECARE TVT 經(jīng)閉孔吊帶 GY

7、NECARE TVT 螺旋穿刺針 GYNECARE TVT 蝶型導引器Blister package Shown with TyvekLid removed吊帶吊帶錐形頭的塑料管連于帶錐形頭的塑料管連于帶 塑料外套的藍色塑料外套的藍色 普理靈網(wǎng)帶普理靈網(wǎng)帶塑料管和組件的資料塑料管和組件的資料- 聚乙烯聚乙烯 - 聚亞安酯聚亞安酯 塑料管直徑塑料管直徑4.2-4.8毫米毫米 (從尖錐部究竟部從尖錐部究竟部)螺旋穿刺針螺旋穿刺針 預先放置于塑料套內(nèi)預先放置于塑料套內(nèi) 固定在塑料套內(nèi)固定在塑料套內(nèi) 資料資料 聚碳酸酯的手柄聚碳酸酯的手柄 - 不銹鋼穿刺針不銹鋼穿刺針Bendable Tabs6 cm

8、7 cm蝶型導引器有助于螺旋穿刺針準確一致地穿過組織6公分長, 可以延伸至7公分.Workstation DesignWith left hand, grabHelical Passer forpatients right sideWinged Guide slidesout of workstation inthis directionWith right hand, grabHelical Passer forpatients left sideAfter grasping both handles andremoving, rotatehandles outward Holds Heli

9、cal Passer, Device, and Winged Guide Allows for dumping or aseptic transfer from Tyvek BlisterPatient orientationsymbolProduct Ordering Information Product Code: 810081Review of Procedural Steps& Anatomy病人體位和預備 截石位, 臀部和床邊齊. 這樣床的邊緣不會干擾醫(yī)生穿針的過程. 病人的大腿和腹部盡量堅持垂直. 術(shù)前排空膀胱麻醉 手術(shù)可以在局麻, 硬膜外或全麻下進展. 如進展局麻, 術(shù)

10、者必需: 運用經(jīng)稀釋的,長效麻醉劑(同TVT) 在尿道中段處注射5-10毫升 在皮膚出針點注射5-10毫升 用硬膜外針,在螺旋穿刺針的途徑注射10-20毫升 從陰道切口和皮膚出針點分別注射, 都朝向恥骨結(jié)合和恥骨降支處.Note: The above technique is from Vincent Lucente M.D. - GYNECARE does not recommend any particular anesthesia protocol. - 沿尿道口畫一程度線, 第二條線為第一條線上兩公分, 出針點為第二條線的大腿皺褶外兩公分處. 可以如今就作皮膚切口.Mark the e

11、xit points by tracing a horizontal line at the level of the urethral meatus, and a second line parallel and 2cm above the first line. - Locate the exit points on this second line, 2cm lateral to the folds of the thigh . Optionally, skin incisions may be made at this time.- 用Allis鉗牽夾, 在尿道口下一公分作一個一公分的

12、切口.Using Allis clamps for traction, make a 1cm midline vaginal incision starting 1cm proximal to the urethral meatusSTEP #1: 標志大腿根部的出針點和陰道正中切口- 銳性分別銳性分別Sharply dissect, using blade or sharp scissors (tenotomy or Metzenbaums not Mayo)- 鈍性分別鈍性分別, 運用前推運用前推-撐開技術(shù)向恥骨和恥骨降支的結(jié)合處分別撐開技術(shù)向恥骨和恥骨降支的結(jié)合處分別, 剪刀為程度略向上

13、方向剪刀為程度略向上方向, 角度為角度為45度角度角. Bluntly dissect, using a push-spread technique toward the junction between the body of the pubic bone and the inferiorpubic ramus, orienting scissors horizontally or pointed slightly upward, and at approx 45 degree angle (toward palpable junction) - 突破閉孔膜突破閉孔膜Perforate th

14、e obturator membrane- 略微將剪刀撐大略微將剪刀撐大Spread scissors slightly apart STEP #2: 組織分別至閉孔膜并突破預備STEP #3:插入蝶型導引棒和螺旋穿刺針, 然后取走蝶型導引棒- 在剪刀的途徑中插入蝶型導引棒在剪刀的途徑中插入蝶型導引棒- Insert Winged Guide, into tract at same angle as scissors- 假設(shè)蝶型導引棒沒有突破閉孔膜假設(shè)蝶型導引棒沒有突破閉孔膜, 取出蝶型導引棒取出蝶型導引棒, 用剪刀重新分別用剪刀重新分別.- If Winged Guide does not

15、“pop through obturator membrane, - Remove and reestablish tract using scissors - 蝶型導引棒放置好后蝶型導引棒放置好后, 插入螺旋穿刺針插入螺旋穿刺針, 針尖貼著蝶型導引棒的凹槽針尖貼著蝶型導引棒的凹槽.- With Winged Guide in place, insert Helical Passer, keeping tip in line with the channel of the Winged Guide- 壓住螺旋穿刺針穿過閉孔膜壓住螺旋穿刺針穿過閉孔膜, 覺得突破感覺得突破感.- Press He

16、lical Passer through obturator membrane, feeling “pop- 取走蝶型導引棒取走蝶型導引棒- Remove Winged Guide-一邊旋轉(zhuǎn)穿刺針一邊旋轉(zhuǎn)穿刺針, 手柄部位同時移至中線位置手柄部位同時移至中線位置.Simultaneous rotation and centering of Helical Passer handle-在到達中間位置前不要轉(zhuǎn)到手柄在到達中間位置前不要轉(zhuǎn)到手柄, 和將手柄在程度位置挪動和將手柄在程度位置挪動.由于這樣容易使穿刺針誤入恥骨后由于這樣容易使穿刺針誤入恥骨后空間空間. Do NOT rotate hand

17、le prior to centering or orient handle in the horizontal plane, as either of these motions may increase the potential for the Helical Passer to enter the retropubic space(remember.POP, DROP & ROTATE)STEP #4: 旋轉(zhuǎn)螺旋穿刺針直至手柄轉(zhuǎn)到中間位置-螺旋穿刺針在接近前面設(shè)定的出針點附近穿出螺旋穿刺針在接近前面設(shè)定的出針點附近穿出. Helical Passer should exit n

18、ear the previously determined exit points.- 能夠需求拉一下皮膚能夠需求拉一下皮膚 Slight skin manipulation may be required.- 假設(shè)手術(shù)開場時沒有作皮膚切口假設(shè)手術(shù)開場時沒有作皮膚切口, 那么應該在此刻作皮膚切口那么應該在此刻作皮膚切口 If skin incisions were not created at start of procedure, they should be created now.STEP #5: 針尖傳出皮膚切口- 針尖穿出皮膚后, 鉗夾塑料管頂端- 穩(wěn)住尿道處的塑料管 Stabili

19、ze the plastic tube near the urethra- Remove the Helical Passer by a reverse rotation of the handle, overcoming the detent holding the Plastic Tube to the Helical Passer. STEP #6:鉗夾塑料管-反向轉(zhuǎn)出穿刺針運用器械A(chǔ)fter clamping plastic tip with hemostat (not shown), place thumb at base of Plastic Tube (as shown belo

20、w) and rotate Helical Passer out of Device用止血鉗夾住塑料管頂端, 用拇指握住塑料管的底部, 然后將螺旋穿刺針轉(zhuǎn)出塑料管.-將塑料管和網(wǎng)帶完好拉出皮膚直到網(wǎng)帶顯露, 而且塑料外套的接近陰道切口.STEP #7: 將塑料管和網(wǎng)帶完好拉出皮膚- 完成另一側(cè)步驟后完成另一側(cè)步驟后, 確保網(wǎng)帶平放在尿道下確保網(wǎng)帶平放在尿道下STEP #8: 在另一側(cè)完成步驟2-7 -運用規(guī)范方式調(diào)整網(wǎng)帶運用規(guī)范方式調(diào)整網(wǎng)帶, 比如運用一個鈍性器械比如運用一個鈍性器械Use the standard method for tape adjustment, such as pla

21、cing a blunt instrument between the tape and urethra- Close the vaginal incision. - Cut the tape ends at the exit points just below the skin of the inner thigh. Close the skin incisions with suture or DERMABOND* Topical Skin Adhesive STEP #9: 調(diào)整網(wǎng)帶, 抽出塑料套, 縫合切口* Trademark完成手術(shù)TVT-O的組織分別途徑 分別尿道旁組織 進入恥尾肌起始端后和閉孔內(nèi)肌處的提肛肌弓狀腱下的坐骨直腸窩的前凹處 Enter the anterior recess of the ischioanal f